Varicose veins

Varicose veins are abnormal enlarged twisted veins, typically affecting the superficial veins of the legs. Normally, superficial veins have one-way valves that help blood to flow back to the heart. If these valves become incompetent (open and non-functioning), blood pools in the veins causing them to become swollen and varicose. Sometimes varicose veins can also arise from structural weaknesses in the vein wall, or from higher than normal blood pressure in the veins.

Prevalence
Varicose veins are a common problem, affecting nearly 20-30% of the population, with women more often affected than men by 2-3 times. The most common type of varicose veins are telangectasias. Due to their appearance, they may also be called spider veins, star bursts, thread veins, or matted veins.

Varicose veins - before and after treatment with EVLT.

History, Symptoms, Signs
Some patients experience no symptoms, but choose to see their doctor because they find the cosmetic appearance of varicose veins unsightly. Symptomatic patients may experience:

• dull ache or pressure in the legs after prolonged standing or walking
• sensation of “heaviness” of the legs
• skin changes (such as itchiness, pigmentation, induration)
• recurrent or persistent ulceration
• infection of the vein (phlebitis)
• clots in the vein (thrombosis)

Diagnosis, Assessment
Diagnosis is usually obvious from examination of the legs while the patient is standing. Assessment involves identifying which veins are involved. A doppler ultrasound is often used.

Treatment
Conservative treatment
Patients who are having mild symptoms such as ache or swelling, are advised to avoid prolonged standing and to try compressive stockings.

Surgical treatment
Surgical therapy is usually considered for disease involving the saphenous and great saphenous veins. Surgery involves tying off and stripping the veins. Most people are able to recover quickly, but around 20% will have complications such as pain, bleeding, bruising, haematoma and nerve injury. Rarer but more serious complications include deep vein thrombosis (DVT) and pulmonary embolism (PE). Most usually report a significant improvement in symptoms. Unfortunately, nearly half of all patients will develop some recurrent varicosities within 10 years of surgery.

Ambulatory Phlebectomy
The technique of phlebectomy dates back to 56 BC, when Aulus Cornelius Celcus first described it. Modern ambulatory phlectomy involves the removal of varicose veins through small cuts in the skin. It is a minor procedure performed using only local anaesthetic, that allows the patient to return to normal activities immediately.

The procedure first involves marking out the varicose veins on the patient’s legs. The patient then lies on a bed that is slightly tilted so that the patient’s legs are higher than their head. Local anaesthetic is given and small incisions are made in the skin along the length of the varicose vein. The varicose vein is then extracted by using a special phlebectomy hook to pull it out. The incisions made in the skin are small enough (1-3mm) that they do not require stitches, and leave only small (if any) scars. Afterwards, the patient is required to wear compression stockings or elastic bandages for up to 3 weeks.

Ambulatory phlebectomy. The varicose veins are pulled out and excised.

Ambulatory phlebectomy is generally very well tolerated. Complications are rare, but may include skin pigmentation, bruising, skin blisters, dermatitis, and infection. The long term success rate is high with >90% patients reporting no recurrence of their varicose veins.

Endovenous Ablation
Endovenous ablation procedures are able to effectively obliterate the internal vein space with faster recovery and better cosmetic results than surgery. There are currently a number of endovenous ablation methods available:

• Radiofrequency ablation (RFA)
• Endovenous laser therapy (EVLT)
• Foam sclerotherapy

Endovenous laser ablation. The laser catheter is guided into the great saphenous vein. As it is being withdrawn, the laser heats the vein causing the vein to close up.

Endovenous laser therapy
EVLT utilises a laser to close the varicose vein. A laser fibre is passed through a small cut in the ankle or knee into the varicose vein. Once guided into place by ultrasound, the laser is fired, delivering laser energy to the wall of the vein. This causes the blood to boil and damages the vein walls, which fibrose and close off. After the procedure, the patient will need to wear compression bandages for a number of days. This procedure usually only requires local anaesthesia to be performed.

Like RFA, EVLT has a high success rate, with >95% patients experiencing an improvement in their symptoms. Patients are able to return to normal activities almost immediately. The common complications are similar to that of RFA, with thermal skin damage being slightly more common in this procedure. Since EVLT is a newer procedure, there is not much data on the long term outcomes. One Australian study showed that after 3 years, 80% of patients had veins that remained closed.

Radiofrequency ablation
RFA involves the use of special catheter that is placed within the varicose vein (step 1 in the diagram below) and guided using US to the right areas. A high frequency alternating current is then delivered via the catheter causing it to heat up (step 2 in the diagram). This causes the vein to irreversibly fibrose and close off. The catheter is then slowly withdrawn (step 3 in the diagram). This procedure can be performed under various forms of anaesthesia including general, regional or local anaesthesia.

The process of radiofrequency ablation. 1: The catheter is inserted into the vein. 2: The catheter is activated, heating the vein. 3: As the catheter is withdrawn, the vein closes.

This procedure has a high success rate, with >95% of patients reporting complete symptom resolution. The procedure is also fairly well tolerated, and complications are usually short-lived. The most common complications include bruising, altered sensations, thermal skin damage, inflammation of the veins, swelling of the lymph nodes and rarely DVT. RFA has less recurrence of varicose veins when compared to surgery. In one large study, patients were followed up for 5 years. In that time, 84% of patients had veins that remained closed, and 22% of patients developed varicosities.

Foam sclerotherapy
Sclerotherapy involves injecting a chemical agent (a sclerosant) to induce blood vessel scarring and closure. Sclerotherapy has a long history and has been used to treat varicose veins for over 150 years. The advent of duplex ultrasound and foam sclerosants have marked its return as a simple but effective treatment for varicose veins. In foam sclerotherapy, air is mixed with the liquid sclerosant to create a foam. When this is injected into the varicose vein (under ultrasound guidance), it displaces the blood within the vein and fills the vein. This causes the vein to spasm and scar. The vein can be checked with the ultrasound to see if the injection has been successful. The patient are usually asked to wear elastic compression stockings for 1-2 weeks after the procedure. No anaesthetic is required for the procedure, and patients are able to return to normal activities straight away.

Foam sclerotherapy has a good success rate, with 80-90% of veins remaining closed after 3 years. To improve the success rate, veins may need to be re-injected. Complications are infrequent but may include skin pigmentation, skin sloughing, vein inflammation, transiently enlarged lymph nodes and allergic reaction. A number of studies are currently being undertaken to determine the best sclerosant and technique, as well as the long term outcomes of foam sclerotherapy.

Links
Wikipedia - Varicose Veins
Wikipedia - Ambulatory Phlebectomy
Wikipedia - Radiofrequency ablation in the treatment of Varicose veins
Wikipedia - Endovenous laser therapy
Wikipedia - Sclerotherapy

References

1. Subramonia S, Lees TA. The treatment of varicose veins, Ann R Coll Surg Engl 2007; 89(2):96-100.
2. Sadick NS. Advances in the Treatment of Varicose Veins: Ambulatory Phlebectomy, Foam Sclerotherapy, Endovascular Laser, and Radiofrequency Closure. Dermatol Clin 2005; 23:443-455.
3. Meissner MH et al. Primary chronic venous disorders. J Vasc Surg. 2007 Dec;46 Suppl S:54S-67S.
4. Myers K, Fris R, Jolley D. Treatment of varicose veins by endovenous laser therapy: assessment of results by ultrasound surveillance. Med J Aust. 2006 Aug 21;185(4):199-202.